Esophageal Fistulas Following Redo Fundoplication with Hiatal Mesh

8 May 2025 16:00 17:30
São Paulo
Rubens Sallum Host

Patient Profile & Clinical Presentation

  • Patient: 65-year-old female

  • Previous Surgery: Nissen fundoplication and hiatoplasty with hiatal mesh surgery for symptomatic GERD, 17 years before the present evaluation (Figure 1).

  • 2024 Presentation: Progressive dysphagia associated with epigastric pain and heartburn.

  • Symptom Progression: Current symptoms worsen after each meal.

Diagnostic Evaluation

  • Endoscopy: Retraction with minor erosions sizing less than 5 mm, located 2 cm above the EGJ with migration of fundoplication.

  • Biopsies: Biopsies of erosions were negative for cancer and consisted in chronic esophagitis with reparative alterations.

  • Contrast Swallow: Contrast swallow at that time is represented in Figures 2 and 3.

Figure 2. Contrast Swallow Study

Contrast swallow study with retention at the early stage of the study.

Figure 3. Contrast Swallow Study

During the late stage of the study, contrast swallow study shows a long time clearance associated with epigastric pain.

Redo Surgery

  • Indication: Redo operation was indicated.

  • Intraoperative Finding: Intrusion of the mesh was confirmed as cause of the dysphagia (Figure 4).

  • Mesh Removal: Removal of the mesh with expected difficulty.

  • Fistulas: Two sites of fistula, separated by a 1 cm septum, were found at distal esophagus and confirmed by intraoperative endoscopy (Figure 5).

Management of Esophageal Fistulas

  • The 2 fistulas were then treated with septotomy and endoscopic vacuum therapy, with endoscopy being performed every week to observe evolution.

  • Vacuum Therapy: Following 8 weeks of vacuum therapy (Figure 6), complete closure of the fistulas was observed, confirmed by endoscopy and contrast swallow.

Figure 4. Redo-fundoplication

Redo-fundoplication with intense inflammatory tissues after dissection. The structures shown in the diagram are: diaphragm in blue, esophagus in green and previous mesh in yellow.

Figure 5. Intra-operative Endoscopy

Intra-operative endoscopy with 2 sites of esophageal fistula at distal esophagus separated by a 1 cm septum.

Figure 6. Vacuum Therapy

Six weeks of vacuum therapy.

Time Schedule

  • Santiago Chile: 10 am – 11.30 pm

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Postoperative Outcome

The patient was successfully discharged without any of the previous symptoms.

Panel for Discussion (São Paulo)

Rubens AA Sallum | Ivan Cecconello | Valter N Félix | Júlio Mariano da Rocha | Ary Nasi | Fauze Maluf Filho | Sérgio Szachnowicz | Marcos Tacconi | Francisco CBC Seguro | Edno Tales Bianchi | Rodrigo José de Oliveira | Camila de Câmara | Rodrigo Nicida | Arthur Y Arabi | Alexandra Cirlinas

Topics for Discussion

  1. Mesh or no mesh? That is still the question.

  2. What type of mesh is most suitable today? What are the preferences of the panel?

  3. Revaluation of a fundoplication: Aside from the clinical evaluation, what is (or are) the most important exam(s) to decide redo surgery?

  4. Current options for treating an esophageal fistula.